Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-A propensity score matched analysis

Abstract

Background: Transcatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-the-scope clips (OTSC) have shown superiority to standard endoscopic treatment.

Objective: To compare OTSC treatment to TAE in refractory peptic ulcer bleeding.

Patients and methods: In this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics.

Results: Patients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re-therapy (12.9% vs. 1.5%; p = 0.042) and in-hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04-8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in-hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11-27.43]; p = 0.048) stayed significant.

Conclusions: OTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in-hospital mortality.

Keywords: over-the-scope clips; peptic ulcer hemorrhage; refractory upper gastrointestinal hemorrhage; transcatheter arterial embolization.

FIGURE 1

A flowchart of the study cohort is shown. Clinical success: successful hemostasis (no primary failure) AND the absence of a rebleeding within 7 days after intervention. Failure in the OTSC group: inability to stop the bleeding after placement of the OTSC, and/or if an OTSC could not be placed (after the endoscope was loaded with the clip). Failure of TAE: inability to stop a bleeding via embolization, and/or if a vessel could not be treated in angiography due to anatomical reasons (e.g., bleeding vessel too small for intubation). OTSC, over‐the‐scope clips; TAE, transcatheteral angiographic embolization